Provider Demographics
NPI:1871594499
Name:NORTHLAKE ENDOSCOPY CENTER
Entity type:Organization
Organization Name:NORTHLAKE ENDOSCOPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:BETON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-939-4721
Mailing Address - Street 1:1459 MONTREAL RD
Mailing Address - Street 2:SU 204
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-6900
Mailing Address - Country:US
Mailing Address - Phone:770-939-4721
Mailing Address - Fax:770-939-1187
Practice Address - Street 1:1459 MONTREAL RD
Practice Address - Street 2:SU 204
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-6900
Practice Address - Country:US
Practice Address - Phone:770-939-4721
Practice Address - Fax:770-939-1187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-04
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044047261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000468652AMedicaid
GA000468652AMedicaid